Design and Rationale of Prolonged Nightly Fasting for Multiple Myeloma Prevention (PROFAST): Protocol for a Randomized Controlled Pilot Trial

BACKGROUND

Obesity is an established, modifiable risk factor of multiple myeloma (MM); yet, no lifestyle interventions are routinely recommended for patients with overweight or obesity with MM precursor conditions. Prolonged nightly fasting is a simple, practical dietary regimen supported by research, suggesting that the synchronization of feeding-fasting timing with sleep-wake cycles favorably affects metabolic pathways implicated in MM. We describe the design and rationale of a randomized controlled pilot trial evaluating the efficacy of a regular, prolonged nighttime fasting schedule among individuals with overweight or obesity at high risk for developing MM or a related lymphoid malignancy.

OBJECTIVE

We aim to investigate the effects of 4-month prolonged nightly fasting on body composition and tumor biomarkers among individuals with overweight or obesity with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), or smoldering Waldenström macroglobulinemia (SWM).

METHODS

Individuals with MGUS, SMM, or SWM aged ≥18 years and a BMI of ≥25 kg/m2 are randomized to either a 14-hour nighttime fasting intervention or a healthy lifestyle education control group. Participants' baseline diet and lifestyle patterns are characterized through two 24-hour dietary recalls: questionnaires querying demographic, comorbidity, lifestyle, and quality-of-life information; and wrist actigraphy measurements for 7 days. Fasting intervention participants are supported through one-on-one telephone counseling by a health coach and automated SMS text messaging to support fasting goals. Primary end points of body composition, including visceral and subcutaneous fat (by dual-energy x-ray absorptiometry); bone marrow adiposity (by bone marrow histology); and tumor biomarkers, specifically M-proteins and serum free light-chain concentrations (by gel-based and serum free light-chain assays), are assessed at baseline and after the 4-month study period; changes therein from baseline are evaluated using a repeated measures mixed-effects model that accounts for the correlation between baseline and follow-up measures and is generally robust to missing data. Feasibility is assessed as participant retention (percent dropout in each arm) and percentage of days participants achieved a ≥14-hour fast.

RESULTS

The PROlonged nightly FASTing (PROFAST) study was funded in June 2022. Participant recruitment commenced in April 2023. As of July 2023, six participants consented to the study. The study is expected to be completed by April 2024, and data analysis and results are expected to be published in the first quarter of 2025.

CONCLUSIONS

PROFAST serves as an important first step in exploring the premise that prolonged nightly fasting is a strategy to control obesity and obesity-related mechanisms of myelomagenesis. In evaluating the feasibility and impact of prolonged nightly fasting on body composition, bone marrow adipose tissue, and biomarkers of tumor burden, this pilot study may generate hypotheses regarding metabolic mechanisms underlying MM development and ultimately inform clinical and public health strategies for MM prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05565638; http://clinicaltrials.gov/ct2/show/NCT05565638.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51368.

Oncological Horizons: The Synergy of Medical and Surgical Innovations in Cancer Treatment

The landscape of cancer treatment has witnessed a remarkable transformation in recent years, marked by the convergence of medical and surgical innovations. Historically, cancer therapy faced challenges, including limited efficacy and severe side effects. This narrative review explores the historical progression of cancer treatments, shedding light on significant breakthroughs in both medical and surgical oncology. It comprehensively addresses the medical domain, covering chemotherapy, targeted therapies, immunotherapy, hormonal treatments, and radiological procedures. Simultaneously, it delves into the surgical realm, discussing the evolution of surgical techniques, minimally invasive procedures, and the role of surgery across various stages of cancer. The article emphasizes the fusion of medical and surgical approaches, highlighting neoadjuvant and adjuvant therapies and the significance of multidisciplinary tumor boards. It also addresses innovations, challenges, and the pivotal role of patient-centered care. Furthermore, it offers insights into the future directions and forecasts in the constantly evolving field of integrated oncological care. This review provides a comprehensive understanding of the dynamic and transformative nature of cancer treatment, reflecting the unwavering commitment of the medical and surgical communities in the ongoing fight against cancer.

The effect of different timing of blood transfusion on oncological outcomes of patients undergoing radical cystectomy for bladder cancer: a systematic review and meta-analysis

Highlights

This meta-analysis and systematic review aim to analyze the association between BT and oncological outcomes of patients undergoing RC for bladder cancer, and tries to find out whether the timing of blood transfusion could also have an effect on this relationship. A total of 20 retrospective studies from online databases and other sources are identified and enrolled in this study. The results show that BT administration during RC operation or perioperative period is significantly associated with worse oncological outcomes including ACM, CSM and DR.

Background

Bladder cancer is one of the most common urological malignancies. Radical cystectomy (RC) remains the main treatment for localized muscle-invasive bladder cancer (MIBC) or high-grade non-muscle-invasive bladder cancer (NMIBC). In the process of RC, the administration of blood transfusion (BT) is sometimes needed, however, it may cause transfusion-related complications or lead to worse oncological outcomes. This meta-analysis and systematic review aims to give a comprehensive insight into the association between BT and oncological outcomes of patients undergoing RC, and tries to find out whether the timing of blood transfusion could also have an impact on this association.

Methods

This systematic review and meta-analysis were carried out according to the PRISMA 2020 reporting guideline. We have searched four bibliographic databases including PubMed (Medline), EMBASE, Cochrane Library, and Web of Science with no language limitation. Studies investigating the association between BT and oncological outcomes of patients undergoing RC are identified and included in this research from inception through March 20, 2023. This research calculates the pooled hazard ratios (pHR) and 95% confidence intervals (95% CI) of all-cause mortality (ACM), cancer-specific mortality (CSM) and disease recurrence (DR) using Random Effects models or Fixed Effects models. Subgroup analyses stratified by parameters such as timing of transfusion are also conducted. This meta-analysis was registered with PROSPERO, CRD42022381656.

Results

A total of 20 retrospective studies from online databases and other sources are identified and enrolled in this study. Results show that blood transfusion significantly increased the risks for ACM (HR = 1.33, 95% CI: 1.23-1.44), CSM (HR = 1.25, 95% CI: 1.15 - 1.35) and DR (HR = 1.26, 95% CI: 1.15 - 1.38). However, when stratified by the timing of BT, we find that only intraoperative and perioperative transfusion significantly increased in risks for worse prognosis, while postoperative transfusion raised none of the risks of ACM (HR = 1.26, 95% CI: 0.92-1.73), CSM (HR = 1.08, 95% CI: 0.93-1.26) nor DR (HR = 1.08, 95% CI: 0.90-1.29) significantly.

Conclusion

BT administration during RC operation or perioperative period is significantly associated with worse oncological outcomes including ACM, CSM and DR. Clinicians should consider carefully when deciding to administrate BT to patients undergoing RC and carry out according to current guidelines.

Oncological and functional outcomes of organ-preserving cystectomy versus standard radical cystectomy: A systematic review and meta-analysis

Introduction

Radical cystectomy (RC) is historically considered the gold standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. However, this technique leaves the majority of patients of both sexes with poor sexual and urinary function. Organ-sparing cystectomy (OSC) techniques are emerging as an alternative to the standard procedure to preserve these functions, without compromising the oncological outcomes. We present a systematic review and meta-analysis of the published literature.

Methods

MEDLINE, Embase and Web of Science were systematically searched for eligible studies on 6 April 2021. Primary outcomes studied were both oncological outcomes, specifically overall recurrence, and functional outcomes, specifically sexual function, and daytime and nighttime continence. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. The PROSPERO registration reference number was CRD42018118897.

Results

From 13 894 identified abstracts, 19 studies (1886 male and 305 female patients) were eligible for inclusion in this review. These studies included patients who underwent either whole prostate, prostate capsule, seminal vesicle, nerve, uterus, ovary, vagina and fallopian tube sparing techniques. Four studies included only female patients.Thirteen studies reported oncological outcomes, and overall recurrence rate was similar between the two groups (five studies; OR 0.73; 95% CI 0.38-1.40, p = 0.34). Thirteen studies reported on male sexual function. In men, OSC had significantly greater odds of retaining potency (five studies; OR 9.05; 95% CI 5.07-16.16, p < 0.00001). Fourteen studies (13 on males and 1 female) reported urinary outcomes. In men, OSC demonstrated greater odds of daytime (seven studies; OR 2.61; 95% CI 1.74 to 3.92, p < 0.00001) and nighttime continence (seven studies; OR 2.62; 95% CI 1.76 to 3.89, p < 0.00001).

Conclusion

In carefully selected patients, OSC allows the potential to provide better sexual and urinary function without compromising oncological outcomes. There remains, however, a paucity of OSC studies in females. Further studies are required to make recommendations based on robust clinical evidence.

Value of Geriatric Assessment in Patients With Genitourinary Carcinoma

Objectives: This work aims to evaluatecomprehensive geriatric assessment (CGA) tools to better guide patients with urogenital carcinomas perioperatively and, consequently, to intensify or reduce hospital resource use. Methods: After informed consent, 111patients were included, all aged more than 65 years, with oncological surgery (with proof of a malignancy), a Mini Mental State Examination (MMSE) score of at least 23 points, and a prospective life expectancy of more than 2 months. Patients were divided into 2 groups: prostate cancer (n = 88) and distal urinary tract cancer (n = 29). Further CGA tools were Instrumental Activities of Daily Living (iADL), Activities of Daily Living (ADL), and the Charlson Comorbidity Index (CCI). The relationships between CGA and complications, hospital duration, death rate, and baseline characteristics were analyzed. Results: In comparison with the patients with prostate cancer, those with kidney/distal urinary tract cancer had higher CCI scores (median, 3 vs 2; P <.001), MMSE scores (29 vs 28; P = .031), complication rates (55.2% vs 22.0%; P = .001), and hospital duration (16 vs 10 days; P <.001), as well as more deaths in the group (8 vs 0). Comorbidities (6 vs 2; P <.001), Physical Status Classification System (ASA state [3 vs 2; P <.001]), and median age (74 vs 71 years; P =.008) were all higher in the kidney/distal urinary tract group, and they had fewer problems with postoperative ADL items, which were significantly lower than those of the prostate group (P = .043). Intra- and intergroup comparisons of preoperative and 1-year ADL/iADL values did not differ significantly. Conclusion: These study results underscore the importance of CGA in patients with genitourinary carcinoma; most patients have high regenerative potential. Patients with kidney/distal urinary tract cancers are older, have more comorbidities, and have more postoperative impairments than patients with prostate cancer.

Acute surgical abdomen during the COVID-19 pandemic: Clinical and therapeutic challenges

The present study investigated the effects of the COVID-19 pandemic on the clinical presentation and therapeutic management of acute surgical abdomen. A retrospective study of emergency hospitalizations with a diagnosis of acute surgical abdomen between April and July 2020 vs. a similar period in 2019 was performed. The observation sheets and the operating protocols were analyzed. Between April and July 2020, 50 cases of acute surgical abdomen were hospitalized and treated, compared to 43 cases in the same period last year. The main types of pathology in both groups included: Occlusions (60%, respectively 44.2% in 2019) and peritonitis (32%, respectively 41.8% in 2019). There was an increased rate of patients with colorectal cancers neglected therapeutically or uninvestigated, who presented during the pandemic period with emergencies for complications such as occlusion or tumor perforation (32 vs. 6.97%, P=0.0039). One case, with gastric perforation, was COVID-positive, with no pulmonary symptoms at admission. The number of postoperative infectious complications was lower during the pandemic (2 vs. 13.95%, P=0.0461). As the COVID-19 pandemic appears to be still far from ending, we should learn to adapt our surgical protocols to the new evidence. Oncological patients are a vulnerable group, who were neglected in the first months of the pandemic. SARS-Cov-2 infection may be a cause of abdominal pain and should be taken into account in different diagnoses of acute abdomen in surgical wards. Correct wearing of adequate personal protective equipment (PPE) and respecting strict rules of asepsis and antisepsis are required for preventing in-hospital transmission of infection.

Comparison of NOSES and Conventional Laparoscopic Surgery in Colorectal Cancer: Bacteriological and Oncological Concerns

Background: Colorectal natural orifice specimen extraction surgery (NOSES) is considered to be a scarless operation that avoids the laparotomy of extraction specimen, but bacteriological and oncological concerns are raised with this technique. Objective: The purpose of this study was to compare the oncological and bacteriological outcomes of NOSES and conventional laparoscopic (CL) procedures. Methods: This is a retrospective study of prospectively collected outcomes data. Patients operated with colorectal cancer from January 2016 to December 2019 in Xiangya Hospital were assigned to the group NOSES and the group CL according to the size of the tumor. Prior to dissection, peritoneal lavage fluid was collected for cytological assessment. At the end of the procedure, peritoneal lavage fluid was collected for aerobic culture and cytological assessment. Baseline characteristics and short-term and long-term outcomes for NOSES and CL were compared. Results: Between January 2016 and December 2019, 212 patients were enrolled from our center and 185 patients were analyzed (96 and 89 in NOSES and CL groups, respectively). The bacterial positive rate of peritoneal lavage fluid was 34.4 vs. 32.6% in NOSES and CL groups, respectively (P = 0.80). The positive rate of tumor cells in peritoneal lavage fluid was 7.3 vs. 9.0% in NOSES and CL groups, respectively (P = 0.67). Univariate analysis showed that the positive rate of tumor cells in peritoneal lavage fluid was significantly associated with tumor invasion depth and lymph node metastasis (P < 0.05). T4 (OR = 20.47, 95%CI = 1.241-337.661; P = 0.04), N1 (OR = 5.445, 95%CI = 1.412-20.991; P = 0.01), and N2 (OR = 6.315, 95%CI = 1.458-27.348; P = 0.01) served as independent predictors of peritoneal lavage fluid positive oncology patients. Local recurrence-free survival was not significantly different between two groups (HR = 0.909, 95%CI = 0.291-2.840; P = 0.87). Conclusions: Compared with conventional laparoscopic procedure, NOSES is in conformity with the principle of asepsis and tumor-free technique and can be worthy of clinical application and promotion.

Reconstruction with biological methods following intercalary excision of femoral diaphyseal tumors

AIM

The aim of this study was to assess outcomes of biological (nonvascularized fibula grafts and extracorporeal irradiated autologous bone grafts) methods used for reconstruction of intercalary defects after resection of femoral diaphyseal tumors.

MATERIALS AND METHODS

This study included 28 patients who had undergone intercalary resection in femoral diaphyseal tumors between 2011 and 2016. The mean follow-up period was 24 months (range 12-57 months).

RESULTS

The mean union time for diaphyseo-diaphyseal union was 10.5 and 11 months in nonvascularized fibula group and extracorporeal radiotherapy (ECRT) group, respectively. The mean union time for metaphyseo-diaphyseal union was 6.5 months in both nonvascularized fibula and ECRT groups. Six patients had distant metastasis, and one patient had local recurrence. The mean Musculoskeletal Tumor Society score was 28 at the last follow-up. Two patients had surgical site infection in the nonvascularized fibula group. Implant failure was found in one patient of the ECRT group requiring revision surgery. Three patients had nonunion (two from the nonvascularized fibula group and one from the ECRT group).

CONCLUSION

The present study indicates that the biological reconstruction modalities provide good functional outcomes in diaphyseal tumors of femur. Nonvasularized fibula and ECRT-treated autografts reconstruction provides good results, and union timing is comparable. The outcomes of the current study are promising as compared to the results in the reviewed literature. The reconstruction method depends on the resources available at the oncological center and the conversance with the method of the treating surgeon.

Implementation and evaluation of a sterile compounding robot in a satellite oncology pharmacy

PURPOSE

The purpose of this study was to quantify the impact of robotic technology on efficiency, accuracy, and cost in a satellite oncology pharmacy.

METHODS

A 33-week quasi-experimental study was conducted at an academic, quaternary care institution with 1,119 licensed beds from June 2016 to February 2017 to evaluate the turnaround time (TAT) for preparations compounded by automated robotic compounding technology (ARCT) versus historical procedures. Secondary endpoints included mean preparation time and percentage of doses with a TAT of <30 minutes before and after the implementation of ARCT and were evaluated using time-segmented regression analysis. The cost savings in the satellite oncology pharmacy was determined by comparing usage of closed-system transfer devices (CSTDs) and labor costs between study phases. Accuracy of the intervention was expressed through a descriptive analysis of mean ARCT dose preparation deviations and preparation failures.

RESULTS

Data for 1,453 preparations were included for analysis. The mean ± S.D. preimplementation TAT was 64.1 ± 27.9 minutes, which decreased to 53.2 ± 32.2 minutes after ARCT implementation (p < 0.01). Financial benefit was demonstrated through supply cost savings. Breakeven was estimated at 8.6 years after capital expenditure, with an annualized projected savings of $129,477. The mean ± S.D. deviation of the doses compounded using ARCT was -0.58% ± 0.01% from the ordered dosage.

CONCLUSION

Adoption of ARCT for compounding of admixtures containing 4 oncology agents reduced TAT and preparation time and led to lower expenditures for CSTDs.

Total Glossectomy Without Laryngectomy for Advanced Squamous Cell Cancer of the Tongue: Functional and Oncological Results

BACKGROUND/AIM

Total glossectomy without laryngectomy for large tongue carcinomas still remains controversial, as these defects may go along with dramatic effects on respiration, speech and swallowing. As a consequence, these procedures significantly impact quality of life. Therefore, larger case series are rare. Nevertheless, with the development of free tissue transfer, functional reconstruction has become increasingly popular and encouraging results are reported in the literature.

PATIENTS AND METHODS

We present our experience with complete glossectomy without laryngectomy and free flap reconstruction. A retrospective monocenter cohort-study was conducted. Reconstructive principles, which in our view lead to optimal functional results, are presented. Oncologic, as well as functional results are reported. Functional results were assessed in terms of swallowing ability, decannulation and intelligible speech.

RESULTS

A total of 14 patients met the inclusion criteria. All patients were reconstructed using an anterolateral thigh flap. Complications occurred in 4 patients, 3 of which developed fistula formation. Oral feeding without the need for a gastrostomy tube was resumed in 11 patients (78.6%), 12 patients (85.7%) were able to be permanently decannulated and speech was at least acceptable in 12 patients (85.7%). The three-year survival was 57.1%.

CONCLUSION

Following meticulous reconstructive principles, as well as a proper patient selection, total glossectomy without laryngectomy is a feasible treatment option for advanced cancer of the tongue.

Impact of Calcium and Magnesium in Groundwater and Drinking Water on the Health of Inhabitants of the Slovak Republic

This work aims to evaluate the impact of the chemical composition of groundwater/drinking water on the health of inhabitants of the Slovak Republic. Primary data consists of 20,339 chemical analyses of groundwater (34 chemical elements and compounds) and data on the health of the Slovak population expressed in the form of health indicators (HI). Fourteen HIs were evaluated including life expectancy, potential years of lost life, relative/standardized mortality for cardiovascular and oncological diseases, and diseases of the gastrointestinal and respiratory systems. The chemical and health data were expressed as the mean values for each of the 2883 Slovak municipalities. Artificial neural network (ANN) was the method used for environmental and health data analysis. The most significant relationship between HI and chemical composition of groundwater was documented as Ca + Mg (mmol·L⁻¹), Ca and Mg. The following limit values were set for these most significant groundwater chemical parameters: Ca + Mg 2.9–6.1 mmol·L⁻¹, Ca 78–155 mg·L⁻¹ and Mg 28–54 mg·L⁻¹. At these concentration ranges, the health of the Slovak population is the most favorable and the life expectancy is the highest. These limit values are about twice as high in comparison to the current Slovak valid guideline values for drinking water.

The immunocompromised oncohematological critically ill patient: considerations in severe infections

Sepsis and septic shock remain a major cause of mortality among critically ill patient. This is particularly relevant among cancer patients as highlighted by different series showing that up to one in five patients admitted to intensive care units (ICU) with sepsis have cancer, and also, sepsis is a leading reason for ICU admission in patients with cancer. The classic predictors of mortality among these patients (such as cancer lineage, neutropenia degree, or bone marrow transplantation history) have changed during the last decades, and they should no longer be used to rule out ICU admission. Instead, a newer approach to these patients should be performed taking into account organ failure assessment and prior performance status. When a doubt exists about the criteria for ICU admission, not only a trial of ICU management should be proposed to assert that no patients are withhold of the opportunity for recovering from the acute condition, but also an early admission, to prevent more derangement, and thus impact on mortality.

[Lynch syndrome: case report and review of the literature]

Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) is the most common form of hereditary colorectal cancers. It increases cancer susceptibility, the risk of colorectal cancer in first-degree, endometrial cancer in women, and to a lesser extent, other cancers (ovarian, small bowel, stomach, urinary tract and hepatobiliary). Thus, the cumulative risk of developing colorectal cancer or endometrial cancer at the age of 80 years rises to 20 and 40% respectively. These cancers are characterized by a positive family history, their occurrence at an early age, and by the development of metachronous cancers in the same individual. This syndrome is transmitted in an autosomal dominant manner. The genes whose alteration is associated with the presence of an HNPCC belong to the family of DNA mismatch repair genes (DNA mismatch repair or MMR): MSH2, MLH1, and MSH6 are involved, in decreasing order of frequency, in 35%, 25% and 2% of cases respectively. Colonoscopic and gynecological monitoring is recommended for patients with a constitutional mutation in MSH2, MLH1 or Msh6 genes. We report one of the first moroccan case with Lynch syndrome whose constitutional mutation in the MLH1 gene was identified in a family member with colon cancer. In reply to the inquiry ofother healthy family members, a presymptomatic diagnosis was made allowing to formulate an appropriate monitoring strategy. Our study aims to highlight the role of oncogenetics in the management of patients with cancer and their families.

Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome

AIM

Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections.

METHOD

A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival.

RESULTS

Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease.

CONCLUSION

Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.

The Six-Minute-Walk Test in assessing respiratory function after tumor surgery of the lung: a cohort study

INTRODUCTION

The Six-Minute-Walk Test (6-MWT) is an established and well-validated diagnostic procedure in cardiovascular and pulmonary diseases. The significance of the 6-MWT in the assessment of the respiratory function in tumor patients after lung surgery is yet unclear.

METHODS

The retrospective study included 227 patients following oncological rehabilitation after lobectomy, pneumonectomy or wedge- and segmental resection due to a malignant tumor disease. Spirometry and 6-MWT were performed at the beginning (T1) and at the end (T2) of oncological rehabilitation and correlated with each other. A subgroup analysis on clinically relevant parameters was conducted as well.

RESULTS

A significant improvement of the walking distance measured in 6-MWT as well as of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were detected within the scope of spirometry (all three P<0.01). This effect was demonstrable in all subgroups, except for patients who underwent pneumonectomy. However, a low correlation of the parameters walking distance and FEV1 was observed at both measurement points T1 (rho value =0.21) and T2 (rho value =0.25).

CONCLUSIONS

Measuring the walking distance in the 6-MWT could be a suitable parameter to assess respiratory function.